Back pain occupies a leading position among all pain syndromes, occurs in 80-100% of people and causes long-term disability in 4% of the world's population, is the second most common cause of temporary disability and the fifth mostusual hospitalization. . Constant or frequently recurring back pain can cause severe suffering to patients and significantly reduce the quality of life.
In this article we will tell you what diseases and conditions can cause back pain, how patients with pain are examined and what treatment a doctor can prescribe.
Classification of back pain
From the pathophysiological point of view, nociceptive, neuropathic and dysfunctional pain types are distinguished. Nociceptive pain occurs through direct tissue damage and activation of peripheral pain receptors. Neuropathic pain develops when there is damage affecting the somatosensory system. Dysfunctional pain is formed due to neurodynamic disorders in the central nervous system. As a rule, during the examination of patients with dysfunctional pain, it is not possible to identify organic diseases that can explain the appearance of the pain syndrome. In addition, there are associated pains, a typical example of which is back pain.
Depending on the location of the pain syndrome, there are the following types of back pain:
- cervicalgia - neck pain;
- cervicocranialgia - neck pain that spreads to the head;
- cervicobrachialgia - neck pain radiating to the arm;
- Thoracalgia - pain in the middle of the back and chest area;
- lumbodynia - pain in the lumbar and / or lumbosacral region;
- lumboischialgia - pain in the lower back that radiates to the legs;
- sacralgia - pain in the sacral area;
- coccydynia - pain in the tail.
According to the course of the pain syndrome, acute (lasting less than 4 weeks), subacute (4 to 12 weeks) and chronic (more than 12 weeks) forms are distinguished. In most patients who seek medical help, back pain is acute, lasts for several days, and is easily relieved by nonsteroidal anti-inflammatory drugs and muscle relaxants. In about a third of patients, the pain continues for six weeks and becomes constant. The chronicity of the pain syndrome can lead to the appearance of anxiety and depressive disorders in the patient, the feeling of waiting for pain, the formation of "pain behavior" and irritability. In this regard, the transition of pain into a chronic form requires a different approach to patient management, the choice of more complex therapeutic regimens, including antidepressants.
Depending on the structures of the spine involved in the pathological process, compression or reflex syndromes prevail in the clinical framework of the disease. Compression syndromes develop when altered spinal structures compress roots, blood vessels, or the spinal cord. Reflex syndromes arise as a result of irritation of various structures of the spine. On the basis of localization, vertebrogenic syndromes of the cervical, thoracic and lumbosacral spine are distinguished.
Causes of back pain
Back pain is a common symptom of many orthopedic and neurological pathologies, some diseases of internal organs, metabolic disorders and tumor processes. Let's take a closer look at the most common causes of back pain.
Degenerative diseases of the spine
Osteochondrosis of the spine is one of the most common causes of back pain. The localization of the pain corresponds to the level of the lesion. Thus, pain in the neck, sometimes radiating to the head, indicates pathological changes in the cervical region, pain in the spine in the middle of the back indicates damage to the thoracic region, and in the lumbar region - problems in the lumbosacral spine. Pain in osteochondrosis is usually moderate, dull, constant or periodic, intensifies after physical activity and weakens at rest. For fear of provoking an attack, patients change their body position slowly and carefully.
With the progression of pathological changes, osteochondrosis of the spine can lead to the formation of an intervertebral hernia, which is characterized by transient local dull pain that intensifies during physical activity, a long stay in a static position and disappears in a lying position. Gradually, the pain becomes constant, combined with severe muscle tension; some patients develop lumbago and lumboischialgia - attacks of acute intense pain in the lumbar region and back thigh.
With degenerative changes in the facet joints that connect the articular processes of adjacent vertebrae, spondyloarthrosis develops, which is manifested as local pain that occurs during movements and decreases with rest. As the disease progresses, patients develop morning stiffness and constant dull back pain in the affected area, which increases with prolonged standing.
Another degenerative disease of the spine that appears with dull pain in the back is spondylosis - a chronic pathology that is associated with degenerative changes in the anterior parts of the intervertebral discs, calcification of the anterior longitudinal ligament and the formation of osteophytes in the anterior part. and the lateral parts of the spine. Pain with spondylosis is local in nature, intensifies at the end of the day, against the background of overload, hypothermia, sudden movements, sometimes at night. Spondylosis is characterized by very slow progression; in the absence of other diseases of the spine, clinical manifestations may not worsen for decades.
Abnormalities of the spine
Back pain is often observed with congenital abnormalities of the spine, sometimes combined with neurological symptoms. Some spine malformations are asymptomatic for a long time and appear only in adolescence or even adulthood. Back pain can occur with the following pathologies:
- Spina bifida.The closed form of the pathology is manifested by moderate local pain in the lumbosacral region, which is often accompanied by sensory and reflex disorders and muscle hypotension.
- Sacralization.A congenital anomaly of the spine, in which the fifth lumbar vertebra is completely or partially fused with the sacrum, is a fairly common occurrence and is often asymptomatic, but in some patients it may be accompanied by pain. At an early onset (at the age of about 20 years), the pain appears after excessive physical activity, falling on the feet or jumping, radiation to the lower extremities and sometimes combined with paresthesia. Characteristically, the pain is relieved when lying down and intensifies when sitting on the heels, when jumping or standing. The late onset of the pain syndrome is caused by secondary changes in the joints and vertebrae. The pain occurs in middle or old age and is usually localized only in the lumbar region.
- Lumbarization.A congenital anomaly, in which the first sacral vertebra is partially or completely separated from the sacrum and "turns" into an additional (sixth) lumbar vertebra, is the reason for visiting doctors in approximately 2% of all cases of back pain. the back. Signs of pathology appear at a young age. The clinical picture depends on the form of lumbarization. In the lumbar form, patients are bothered by aching pain in the lower back and along the spine, which is relieved by taking NSAIDs. A characteristic feature of the sciatica form is the radiation of pain in the buttocks and lower extremities. In some cases, a violation of skin sensitivity is detected in the thigh and waist region.
- Wedge-shaped beads.Wedge-shaped vertebrae are a congenital anomaly, less commonly acquired, that can cause spinal deformity and back pain. Patients complain of increased fatigue during physical activity, discomfort and pain in the back. Depending on the location of the pathology, these symptoms may include headache and shortness of breath.
Acquired deformities of the spine
With minor deformations in stages I-II of the pathology, pain is usually absent. As the process progresses, annoying or aching pain appears in the back, which intensifies against the background of physical activity and prolonged uncomfortable position of the body. Pain syndrome is observed with such spinal deformities as pathological kyphosis and lordosis, scoliosis, kyphoscoliosis, Scheuermann-Mau disease. Small back discomfort and pain caused by non-physiological posture and muscle weakness can also be seen in patients with poor posture.
Back injuries
Traumatic injuries to the spine and surrounding soft tissues are another common cause of back pain. The severity of the pain depends on the severity of the injury:
- The injury.When a bruise appears, back pain is usually of a local and moderate nature, goes away after a few days and disappears completely 1-2 weeks after the injury.
- Traumatic spondylolisthesis.Displacement of the vertebrae of a traumatic nature occurs more often in the lumbar region. Patients complain of moderate or intense pain in the lower back, which radiates to the legs. Palpation of the spinous process is painful, the axial load symptom is positive.
- Compression fracture of the spine.The injury is usually caused by a jump or fall from a height. Traumatic injury is accompanied by sharp pain; with a fracture in the spine, severe pain in the middle of the back is often combined with difficulty in breathing. Then, the patient complains of pain in the projection of the damaged vertebra, sometimes radiating to the abdomen. Pain decreases when lying down, increases with coughing, deep breathing, movements, as well as with standing, sitting and walking.
Osteoporosis
Osteoporosis is a pathology of the bone tissue, which is accompanied by a decrease in mass, a decrease in strength and an increase in bone fragility. In most cases, the disease is asymptomatic and is detected during an X-ray examination. However, some patients with osteoporosis may experience minor pains in the spine, most often in the chest and lumbar region, which intensify with physical activity. Sometimes back pain is combined with pain in the ribs and hip joints.
Inflammatory and infectious diseases
A dull ache and feeling of stiffness in the lower back can be the first signs of ankylosing spondylitis, a chronic inflammatory disease of the spine and joints. Characteristic of this pathology is the appearance of pain at night, intensification in the morning and reduction of its intensity after physical activity or a hot shower. During the day, the pain increases even at rest and decreases during physical activity. As the disease progresses, the pain gradually spreads throughout the spine, its mobility is limited and thoracic kyphosis is formed.
Back pain can occur due to post-traumatic or postoperative osteomyelitis - inflammation of the bone marrow, which affects all elements of the bone (periosteum, spongy and compact substance). With vertebral osteomyelitis, pain in the spine usually has a clear localization, is of an intense explosive nature, sharply intensifies when trying to move and is combined with hyperthermia, weakness, fever and marked local edema.
When the infection penetrates into the subdural space of the spinal cord, a spinal epidural abscess can form, which is manifested as diffuse back pain and an increase in body temperature to high values. Patients experience local stiffness of the spinal muscles, pain at the impact of the spinous processes and positive symptoms of tension. As inflammation increases, a decrease in tendon reflexes is observed, paresis, paralysis and pelvic disorders appear.
Infectious inflammation of the arachnoid membrane of the spinal cord leads to the development of spinal arachnoiditis, which is manifested by transient pain in the area of nerve root innervation. Gradually, the pain in the spine becomes permanent, recalling the clinical picture of radiculitis, they are accompanied by sensory disorders and motor disorders and a possible loss of control over the functioning of the pelvic organs.
Neoplasms of the spine
Benign tumors of the spine are often asymptomatic or associated with mild, slowly progressive symptoms. The most common tumors of the spine that are detected in patients of any age are hemangiomas. In approximately 10-15% of cases, they are accompanied by local pain in the back, which increases after physical activity and at night. The cause of the development of pain in the spinal hemangioma is the irritation of the pain receptors of the periosteum and the posterior longitudinal ligament.
Among the malignant tumors of the spine, spinal sarcoma is diagnosed most often. In the initial stage, the disease is characterized by constant mild or moderate pain, which worsens at night. The intensity of the pain increases quickly. Depending on the location of the tumor, patients experience pain in the arms, legs and internal organs.
Pain in the spine can also be a sign of metastases of internal organ neoplasms. Initially, the pain is local, dull, aching, reminiscent of the clinical picture of osteochondrosis, but it quickly progresses, becomes constant and, depending on the location, may radiate to the arms or legs.
Risk factors for the development of back pain
Factors that can cause back pain can be divided into correctable and non-correctable (heredity, age, gender). Modifiable factors include:
- professional(work associated with lifting heavy objects, static loads on the spine, monotonous physical work, including frequent forward bending and turning of the body, work associated with vibration processes);
- psychosocial(muscular discomfort caused by staying under acute and/or chronic stress conditions);
- individual physical and somatic characteristics(scoliosis, kyphosis and other spinal deformities, weak muscle tone, monotonous stereotypical movements);
- Poor nutrition and gastrointestinal diseases(malabsorption of B vitamins, consumption of foods with a large amount of purine bases, overweight);
- bad habits(smoking, alcohol abuse).
These risk factors are quite common, but can be eliminated or limited by the duration of exposure. Against the background of such predisposing factors, hypothermia, difficult movements or acute stressful situations are enough to form a pain syndrome.
Examination of patients with back pain
The main tasks of a neurologist when examining a patient with acute or chronic back pain are to establish an accurate current diagnosis and etiology of the pain syndrome. At the initial meeting, the doctor talks with the patient, revealing all the circumstances related to the occurrence of pain.
Taking history
Although patients describe pain differently, a careful history may suggest pathophysiological mechanisms underlying the pain syndrome.
Thus, the development of acute pain with a clear localization, which is well relieved by taking analgesics and is not accompanied by a violation of surface sensitivity, is characteristic of nociceptive pain syndromes associated with damage to spinal joints, ligaments and muscles. Burning, shooting pain that radiates to the extremities and is accompanied by sensory disturbances can be caused by compressive radiculopathy.
Pain associated with damage to internal organs often does not have a clear localization, may be accompanied by nausea, skin discoloration, excessive sweating, is often spasmodic in nature and radiates to the opposite half of the body.
It should be noted that low back pain without radiation to the limbs in patients under 50 years of age (in the absence of a history of malignant neoplasm, clinical signs of a systemic disease and neurological deficit) with a probability of up to 99% is caused by musculoskeletal disorders, for example, myofascial pain syndrome or joint pain - ligamentous dysfunction.
However, even during the patient's first examination, the doctor pays attention to the signs that indicate that back pain may be a symptom of a more serious pathology. So, the presence of temperature, local pain and an increase in local temperature in the paravertebral region may indicate an infectious lesion of the spine, weight loss without cause, a history of malignant tumors, persistence of pain at rest - a malignant neoplasm of the spine. colon, accompanying uveitis and arthralgia - spondyloarthritis.
Examination of the patient
A physical examination for back pain in most cases makes it possible to determine the source and pathogenesis of the pain syndrome, suggest or accurately determine the nature of the underlying pathological process.
During the neurological examination, the doctor pays attention to the posture, posture and gait of the patient, checks for contractures, deformations and asymmetry of the limbs, assesses the condition of the spine, clarifies the presence and nature of motor, sensory and trophic disorders. disorders and changes in tendon reflexes. Based on the survey data and examination results, the neurologist prescribes additional tests for the patient.
Laboratory and instrumental diagnosis
Laboratory and instrumental research methods help to perform differential diagnosis, confirm or reject the suspected diagnosis.
When examining patients with back pain, X-ray spondylography with functional analysis, computed tomography and magnetic resonance are informative. For acute back pain, patients are advised to perform general and biochemical blood tests and urine tests.
In some cases, neuroimaging methods such as computed tomography and magnetic resonance come to the fore. Radioisotope scintigraphy is used to diagnose local inflammatory or metastatic processes. The diagnosis of osteoporosis is based on densitometry. To determine the level of damage to the structures of the spinal cord and the peripheral nervous system, including to clarify the nature of the radiculopathy, electroneuromyography is performed.
Back pain treatment
The main objectives of treatment of patients with back pain are to relieve pain, prevent the progression of chronic disease, ensure the conditions for a full course of rehabilitation measures and prevent the recurrence of irritations.
The basis of conservative treatment of the pain syndrome consists of non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, neurotropic vitamins and some other non-drug methods, which mainly affect the nociceptive component of pain, including massage, exercisetherapeutic, manual therapy.
During the acute period, excessive physical activity is excluded, but instead of long-term bed rest, such patients are shown an early return to the usual level of activity to prevent the formation of chronic pain syndrome. Strict immobilization is recommended for the first three days. For acute pain in the lower back, a fixation belt is used; for neck pain, a cervical collar is used. However, long-term fixation of the cervical or lumbar spine is not recommended, except in selected cases, such as vertebral fracture or the presence of lumbar spondylolisthesis.
With the regression of the pain syndrome, patients are prescribed physiotherapeutic procedures: ultrasound, magnetic therapy, electrical stimulation, reflexology, exercise therapy and massage are recommended, and manual therapy is performed according to indications.
In case of vertebral instability, spinal cord compression, intervertebral hernia or neoplasia, the patient may be recommended surgical treatment. The type and extent of surgical intervention are chosen individually by the attending physician or a medical council. After surgery, antibacterial and analgesic agents, neurotropic vitamins and other drugs are used, and rehabilitation measures are carried out, including physiotherapeutic techniques, massage and physical therapy.